Permission Form

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St. Francis Xavier Parish Permission Form 155 Stringer Lane, Mt. Washington, Ky. 40047 I, ______________________________(parent/guardian) Request that my child ________________________________ be allowed to go to Kings Island on Tuesday, June 14, 2011 and/or Holiday World Wednesday, July 20th, 2011. (please circle appropriate theme park)
I further give permission for my child to ride in any vehicle designated by the adult in whose care my child has been entrusted while participating in the above activities. In consideration of permitting my child to attend and/or participate, I do hereby for myself and my child (children) waive and release any and all claims that I might have against the Office of Youth Ministry of Saint Francis Xavier Parish, St. Francis Xavier Parish, the Archdiocese of Louisville and any adult in whose care my child is entrusted to, including any designated driver of a van, bus, car or vehicle, for any and all injuries or losses suffered by said child (children) while engaged in the above activities.

Allergies:________________________________________________________________ Is your child currently taking any medication?_________________________________ Do we have your permission to dispense Tylenol or Advil, if needed?_______________
In case of any medical emergency, I understand that every effort will be made to contact the parents or guardians of the child participating in the Youth Ministry Programming of the Parish. In the event that I cannot be reached, I hereby give permission to the physician selected by the Coordinator of Youth Ministry to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child, as named ______________________________________________ herein. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned youth pursuant to this authorization.
Signature of Parent/Guardian________________________________Date____________ Address__________________________________________________________________ Home Phone ______________________Cell _____________Work ________________ Emergency Contact________________________________________________________ Home Phone_______________________ Cell ____________Work _________________ Insurance Carrier______________________________________Policy Number__________________

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